O&G: Early pregnancy

Question 1

Which of the following is the greatest risk factor for hyperemesis gravidarum?

Low maternal BMI

Second and successive pregnancies

Twin pregnancy

Increasing maternal age

Maternal epilepsy

Answer 1

Twin pregnancy

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Increasing maternal age decreases risk

Multiple pregnancies have been associated with hyperemesis gravidarum, as have molar pregnancies, thought to be due to the increased placental mass (and therefore higher beta-hCG levels). In fact, young maternal age, first pregnancy and obesity also have suggested as factors associated with the condition.

It is not uncommon for women to feel nauseated in pregnancy, and for most this settles by around 16 weeks pregnancy. If the vomiting is prolonged (over a longer period during the pregnancy) or extensive (in frequency each day) then it can become problematic.

Many factors have been suggested as being implicated in causing nausea and vomiting in pregnancy including: high beta hCG levels (which is supported by the higher incidence of N&V in molar and multiple pregnancies), high oestrogen levels, nutritional deficiency (vitamin B6 in particular) and gastric dysfunction due to smooth muscle relaxation in high progesterone states, amongst others.

Question 2

First line treatment for hyperemesis gravidarum?

Answer 2

Antihistamines (Eg Promethazine)

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Cyclizine could also be used

Question 3

Complications of hyperemesis gravidarum?

Answer 3

Maternal:

Wernicke’s encephalopathy

Mallory-Weiss tear

Central pontine myelinolysis

Acute tubular necrosis

Fetal:

small for gestational age, pre-term birth

Question 4

You’ve got a presentation of molar pregnancy at 8 weeks. What would you expect of the Beta hCG, TSH and Thyroxine levels?

Answer 4

Raised beta hCG, low TSH, high thyroxine

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Beta hCG mimics TSH, causing increased thyroxine. Negative feedback reduces TSH.

Question 5

A 25-year-old present 8 weeks after her last menstrual period. She complains of severe nausea, vomiting and vaginal spotting. Pregnancy test was positive and transvaginal ultrasound showed an abnormally enlarged uterus. What is the most likely diagnosis?

Answer 5

Molar pregnancy (aka Hydatidiform Mole)